a medical librarian's adventures in evidence-based living

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April 05, 2011

"Chronologically, you might be 61-years old. But, physiologically, you're a 51-year old, or maybe even a 41-year old.

So, we need to make sure your bones will last as long as the rest of you!"

-What My Physician Told Me Last Month-

Just got back into town at midnight last night after five days in St. Louis visitng the "kids". I've got a list a mile long of posts I want to write--but Today's To-Do List is grabbing all my attention. Ughh!

Unpacking & Laundry

Grocery shopping

Making dinner

A plant-based-gluten-free Passover Seder to plan--Help! Does anybody know how to make matzo balls without eggs or oil?

Phone calls to return

And that's just for starters.

This post will be a quick one! Well, not exactly, I guess.

My March Visit to the New Doctor

Last month I was due for:

My once-every-three year Pap test

My once-every two year bone density test

My once-a-year mammogram

But, it was time to see a new doctor--someone I didn't need to schedule 7 months in advance, who was a little less quick-on-the-prescription-trigger & a lot more diet & exercise savvy. My friend Mina gave rave reviews for the gynecologist she now sees--so I decided to give her a try.

Dr. M seemed like the right choice for me. But, honestly, before my appointment all I knew about her was that she was a popular well-respected physician at the hospital where I work--and that she was currently working on a paper that connected a diet high in dairy & animal protein with fibroids. Sounded intriguing to me.

Yikes! Who Knew Such a Physician Existed?

Imagine my surprise when I finally met her, and found out that:

She eats plant-based--with occasional fish. She's eaten this way all her life--coming from a poor country where she told me people eat lots of squash, beans, and corn--and most are healthier than many Americans, in spite of their lack of access to medical care.

She's a faculty member at a top-notch medical school.

She's a walking testament to everything she advocates---a plant-based diet, exercise, making time for meditation/relaxation/down-time.

This doc knows the research! And, she was asked to write the chapter on genetics and epigenetics for the Dr. Oz/Dr. Roizen You Having a Baby book.

We were on the same page about diet, dairy, calcium,vitamin D, animal protein, exercise, bone-strengthening drugs, and HRT--of which I take a very low dose.

Here's What I Learned at My "New Doctor" Visit

It was a thumbs up for my plant-based diet. Dr. M. was thrilled that I was following a nutrient-dense, plant-based no-added oil diet. When she walked into the room, she told me, "You're not the 61-year old woman I was expecting to see! Keep doing whatever you're doing!"

No chastisements about my lack of dairy. She and her family also abstain. No milk for her kids after they finished breast-feeding. No worries about how I was going to get enough protein or calcium, either. She understood plant-based.

Dr. M on Vitamin D

A year ago my vitamin D 25 hydroxy test score was 34.3. Not bad. It had moved out of that too-low-under-30 range--putting me in the "low-but-OK" target zone needed to adequately absorb calcium. But, frankly, I'm not so great about regularly taking vitamin D supplements. And forget about getting enough "outdoor sun time" where I live.

OMG! Taking vitamin D never tasted so good! And I have no problem remembering to take gummies. You are going to love this delicious way to get your vitamin D. They're at Whole Foods, but if you order them from Vitacost you'll save yourself 40%.

Just so you know--Rainbow Light is D3 which comes from lanolin, making it a "deal-breaker" for ethical vegans who will only take D2. It's also a "deal-breaker" if you object to the small amount of sugar that's in each gummy.

I bought the 1000 IU bottle of 100 gummies--so at 4/a day, one $9.95 bottle lasts for 25 days. A lot more expensive than the generic vitamin D you can get elsewhere--but at least I take these.

I brought a bottle of these gummy gems to St. Louis last week so my sons & daughter-in-law could try them out. Definitely a winner.

Sure, vitamin D from the sun is best--but I just can't seem to get enough of the real thing living where I do--and working an inside library job!

Unless you live south of a line from Los Angeles to Columbia, S.C., there may not be enough sunlight year round to produce all the vitamin D you need. Click here for more info

How much to take?

That's between you & your doctor. You're dancing in the dark if you start taking vitamin D without first taking a 25-D hydroxy test to see what your blood level is. I take 4000 IUs and Dr. M thought that was fine. The latest 2010 Institute of Medicine guidelines for vitamin D increased the upper limit for vitamin D to 4000 IUs, even though the IOM recommends that females between age 51-70 get just 600 IUs a day. Talk to your doctor!

The Breast Cancer & Vitamin D connection--maybe a reason to up the ante.

Dr. M told me that recent research is indicating that we might need to get our vitamin D levels much higher than previously thought, especially when it comes to preventing breast cancer--like levels as high as 40-70 as measured by the 25-D hydroxy test. She also told me that recent studies have demonstrated that early breast cancer survivors with the highest blood levels of vitamin D had the fewest cancer recurrences. Click here, here, and here to read more about the cancer & vitamin D connection. But stay tuned--as always, more research is needed before recommendations start to change.

"We found that daily intakes of vitamin D by adults in the range of 4000-8000 IU are needed to maintain blood levels of vitamin D metabolites in the range needed to reduce by about half the risk of several diseases -- breast cancer, colon cancer, multiple sclerosis, and type 1 diabetes.

I was surprised to find that the intakes required to maintain vitamin D status for disease prevention were so high -- much higher than the minimal intake of vitamin D of 400 IU/day that was needed to defeat rickets in the 20th century."

Dr. Bruce Hollis has collaborated with Dr. Walter Willett and the Harvard School of Public Health for over 15 years, studying epidemiologic data on the effects of vitamin D on cancer. These studies have routinely shown that an adequate vitamin D status protects against 13 or 14 different cancers, including breast, prostate, and colon cancer.

Hollis is skeptical that vitamin D could treat cancer once you get it--its benefit is in preventing it in the first place--and having adequate levels will lower your risk.

Researchers in Nutrition Reviews project that a vitamin D blood level over 52 ng/mL would reduce breast cancer by 50%, and levels over 34 ng/mL would prevent 50% of the colon cancers.

Here's how it works: Vitamin D helps control cell growth and that's why we think that it will reduce the risk of many deadly cancers like prostate, breast, and colon by as much as 50 percent. In its role as a hormone, vitamin D travels all over our body delivering messages to activate genes and control cell growth.

If a cell turns cancerous, vitamin D delivers the instructions for that cell to self-destruct. Not enough vitamin D and that cancer cell might keep reproducing. According to Hollis, "vitamin D acts as a brake" when it comes to cancer. It prevents cells from growing wildly out-of-control--and this mechanism has been studied for years.

Dr. M told me that she is now recommending that we get most of our calcium from our diet, rather than from supplements--and that we need less calcium than previously recommended. Think more in the range of 500-800 mg/a day of calcium, rather than 1200 mg/a day. Exactly what Harvard's Dr. Walter Willett is advising--click here.

Even on a plant-based diet, it's not that hard to get 500-800 mg of calcium a day if you eat lots of low-oxalate leafy greens like kale (spinach is highest in calcium-blocking oxalates), drink calcium-fortified non-dairy milk, eat "calcium-set" tofu, and add a 250 mg Citracal calcium tablet into the mix if need be. It's a piece of cake. On a typical day, without even taking a calcium supplement--I get around 1000 mg of calcium just from eating plant-based.

So what's the big concern with taking too many calcium supplements?

A recent New Zealand meta-analysis in the well-respected BMJ linked calcium supplements (with & without vitamin D) to an increase in myocardial infarctions. Read more about that research here.

According to Ian Reid, a Professor of Medicine at the University of Auckland, New Zealand & the author of the BMJ meta-analysis:

"I don’t prescribe calcium supplements to anyone anymore for preventing bone fractures. People should get calcium from their diet. We believe there is a fundamental difference between dietary calcium and supplemental calcium." He speculated that a calcium supplement, even at a relatively modest dose of 500 mg, produces a "borderline hypercalcemia" that persists for several hours and raises the risk for MI or stroke, the same way that people in the highest quartile for normal blood calcium levels have an increased risk for cardiovascular disease events.

Strong Bones? Exercise or Bisphosphonates for Osteopenia?

Me: "I'm due for a new bone-density scan this month. What do you think about the bisphosphonates if it turns out I'm losing too much bone?"

My 2011 bone scan results are now in: No significant changes since the previous one in 3/2009, Yay!--but, the downside is that I still have some loss since my 2003 pre-menopause scan.

My current exercise routine might need a tune-up:

Spinning 3 times a week--a good choice for cardiovascular health--but it doesn't do a thing for building bone density. It's just not weight-bearing--read more about biking & bone loss here. More walking or step aerobics would be better bone building choices, but I'm not about to give up spinning!

Yoga--3 times a week--a good choice for putting stress on all of my the bones--including the back, the hip, the wrists, the ankles, & the toes. For more on how yoga strengthens bones, click here and here.

Weight-training--once a week--this one needs to be increased. Maybe it's time to stop talking about that 10-20 minute kettle bell DVD work-out I've been wanting to try--and just start doing it!

Exercise - Strength-Training Has a Profound Effect on Strengthening Bones

The BEST Study (which stands for Bone Estrogen Strength Training study) was conducted in Arizona betwen 1995 and 2001 and is considered to be a seminal study in osteoporosis. The study looked at 266 sedentary postmenopausal women, ages 44-66, all in relatively good health. The subjects were all nonsmokers. About half of them were on hormone replacement therapy, the others were not. Every participant took a daily calcium supplement--making an equal playing field. The subjects' bone density was measured prior to the test using the Bone Mineral Density (BMD) test.

Participants in the BEST study were divided into two groups, half taking hormone replacement therapy and half not. The object of the study was to determine what effect weight-bearing exercise had on bone mineral density (BMD) when the only variable was exercise. So one group on each team (those taking hormones, and those not) undertook a strength-training program, while the others had no regular strength training at all.

Exercisers performed supervised aerobic, weight-bearing, and weight-lifting exercises, three times per week in community-based exercise facilities. To encourage and maintain interest in exercise for one year, the women in the strength-training group participated in social support programs resulting in a high level of adherence.

The findings were startling. The participants in both groups who exercised--whether they were taking hormones or not--had markedly improved bone density in their hips and low backs, the areas of focus for the study. (The hormone-taking group showed a slightly higher, but not significant, level of improvement.)

Among non-exercisers, the hormone-taking group showed a slight increase in bone density while the other group showed no improvement at all--or, even worse, showed a decrease in bone density.

The study powerfully showed that a dramatic increase in bone density and strength can occur with regular, weight-bearing exercises.

What About Squatting for Strong Bones?

Yoga Squat

Traditional Squat without Weights

My Grandson Demonstrates Proper Squat Form

Two weeks ago, Dr. Susan Brown had a fascinating post about the benefits of the squat on her Bone Health blog.

It turns out, hip fractures have recently started to increase in China, and one researcher thinks it might have something to do with China's move from the hole in the ground "squat toilet" to the modern "throne toilet".

Hip fractures increase as falls increase--and falls increase when women lose strength, flexibility & balance. All of which they once had from the daily use of squat toilets. Something to think about!

Think of how many strength, balance, & flexibility opportunities we are passing by just because we have modern plumbing. To read more, click here.

According to blog reader Tom, we only got into "this position" by historical accident thanks to Western royalty wanting a dignified sitting position (they always went in front of their servants). Until 1850, everyone except royalty used the squat position.

But, look there's no way we're going back to the squat toilet. The logical solution is to just do the traditional weight-training squat, the yogic "awkward chair pose", known as utkatasana, or the yoga squat, known as malasana--click here to read more.

If you're really interested in learning more about the health benefits of squatting--and there are plenty- click here.

Vacation Photo: Sunday in St. Louis' City Garden- a balmy 83 degrees

If you haven't read or listened to this before, it's an eye-opening piece by Alix Spiegel of NPR:

Have you noticed Isa's recipe for vegan matzoh balls in Vegan with a Vengeance? I made them once a few years back, and they were pretty good. (The accompanying recipe for vegan chicken soup was very good too.) She uses oil, but I'm thinking - why not substitute cashews or pine nuts? I'd soak them overnight first, then puree them in the Vitamix. I might also try avocado. That leaves surprisingly little taste of avocado when you use it as a fat substitute in baking; why wouldn't it work the same in matzoh balls? Other than turning them a bit green, which might actually be pretty. You could add some parsley and make it look like the color was intentional.

I am curious about what you think about McDougall too. I check and double-check everything he says, and every once in a while I feel like he's fudging data to make his own case, but with the Vitamin D thing, I don't see where that's happening.

Wendy & Barbara---I'm sticking with Dr. Michael Holick & Dr. Bruce Hollis' vitamin D research over Dr. McDougall's. I've read a lot about D & the research as well as the actual benefits when it is increased to sufficient levels is compelling--and where I live there is no way I could ever get enough natural D. McDougall lives in CA. Besides, I make up my own mind about things--and don't buy into any one person's viewpoint.

After listening to the NPR report (that you referenced) about the made-up disease of osteopenia, I had my wife get off the prescription med (of course, she consulted with her doc).

If anyone is "on the fence" about doing strength-training, I recommend this video at my site http://www.feedyourheaddiet.com/exercise.html. This is the video that convinced me to start training with weights. No doubt, it has made for a very positive health-change.

Excellent post, as always! Thanks! I love the feeling of getting stronger after a weak and skinny childhood. Weight-lifting has been helped me address an inherited joint condition (building muscle around weak/unstable joints), and I hope it helps me avoid the family osteoporosis. Granny went from an estimated 6 feet tall in her youth (she always hunched over, trying to look shorter), to a bent 5 ft 2 or 3 before she died at age 88. I stand tall, and my father-in-law asked me at Christmas (after 6 months back in the gym) if I was growing!
At 40, I don't think so, but the exercise certainly helps me avoid shrinking.
It has such positive effects on your self confidence (yes, I can lift that bag of potting soil, thanks) as well as your bones. Well worth the effort!

Crewmom--Re rowing--do you mean like outside crewing with a group, or using a rowing machine? Are you on a crew team? Never thought about the rowing machine--but, you're right, it's a great way to build a strong back.

Mitzi--I know exactly how you feel! It's so empowering to feel strong, and capable of lifting heavy loads. What kind of weight routine are you following?

As someone who was vegan for nearly a decade I sympathize with those who strive to eliminate all animal products from their lives. However, I would strongly encourage vegans to consider using D3 for the following reasons:

1) D3 is the form humans and fish make. D2 is not found in any appreciable amounts in the human body.
2) D3 has higher biological activity than D2. Yet evidence suggests D2 is more toxic in overdose.
3) D3 is the form of vitamin D used in most clinical trials.
4) D3 is more shelf-stable, which means the amount in the bottle is more accurate.
5) Contrary to popular belief, the two forms follow slightly different metabolic pathways. This may be clinically significant.
6) Prescription vitamin D is D2 -- not because it is better, but because the FDA has not classified D3 as a drug (it's a supplement). D2 is a lot cheaper than D3, but that is its main advantage.

It seems imprudent to take a less effective, possibly more toxic form of vitamin D when there are known problems associated with both vitamin D deficiency *and* toxicity (excess). Perhaps a company would consider making D3 from more humanely produced sheep wool (i.e., shear the animals carefully so they don't lose tails and give them a good, free-range sort of life). Going out in the sun is not enough for anyone who lives north of Georgia, and even then vitamin D production is still low in winter.

I got interested in rowing when my daughter joined her high school crew team, and the erg was a godsend after having both hips replaced. It completely rehabbed my shoulders (wrecked after so much time on crutches) and has stabilized my knees after botched knee surgery when I was a teenager. It does give you a strong back, but also so much more! Here's a link to some of the benefits:

Do invest 5 minutes and get some instruction from either a live coach (I call my daughter the "Form Police")or any of the excellent videos around. If you're close to water, there are lots of groups (regular rowing and dragon boating as well) but for me the erg is the best.

I do the basics- I used machines (curls and extensions), swimming, and stretching to rehab 2 knees dislocated in a dreadful martial-arts grappling accident. Now I can do full squats again (many years later)! For a shoulder injury, I used light dumbells (5 lb, then 10, now 20!) to stabilize the muscles of the rotator cuff over time. Now I'm off the chest press machine and can do bench press with the bar+10 pounds or 2 20-pound dumbells. I use plank and ball work for abdominals, and ride a reclining bike for warm-up (which surprisingly stabilized my ankles). I also use a weight-assist machine for chin-ups and dips, and hope to be able to chin-up my own body weight by this time next year, for the first time EVER. I do this three times a week, and walk on off-days in addition to parking at the back of lots, taking stairs, etc. All my joints are hyper-mobile and can partially (or fully) dislocate at times, so I have to be extra careful to stabilize the joint, then strengthen the muscles. If you are not sure about your technique, start on the machines or with an instructor. It is worth it to pay a qualified professional to tell you how to do things right, for your body and medical history. Then work your way to the free weights and more functional movements (like squats, dips, and chin-ups) as you gain confidence and skill.

Honestly, I don't if standing or squatting while spinning makes it weight-bearing--but I did see this (4 years old though) on Dr. Miriam Nelson's Strong Women website:

Q: Does a Spinning class count as weight-bearing exercise?

A: Spinning is a great aerobic workout and because most Spinning classes involve several minutes of standing climbs, it can be considered a hybrid of both weight-bearing and non-weight-bearing exercise. As far as I know, there isn’t any research that looks at the relationship of Spinning and bone health. If your goal is to keep your bones strong, be sure to keep up with your traditional strength-training program, too.

I just found your post, referred by a fellow blogger. It's fascinating and I will be spending lots of time over the next few weeks reading older posts. Thanks for putting it all up here for others to see. I'm a breast cancer survivor and always searching for new ways to keep healthy. So...THANKS. I'll be back......
Claudia

Just wanted to take exception to your statement, "But look, there's no way we're going back to the squat toilet."

Once all the benefits of squatting have been validated, people will realize that their children deserve to be spared the fate our generation has suffered. We are leaving the world in such a mess in so many ways -- why not let our children at least enjoy a healthier and more natural defecation and childbirth posture?

I was missing my "DEB" fix last week! I'm glad you're back and had a great visit with the kids...so rejuvenating. I just used my teacher discount at Borders to buy Isa's new book...Appetite for Reduction (love the play on words from Guns 'n' Roses Appetite for Destruction)...she must be a rocker! It looks great and can't wait to dive in to the wonderful recipes. You mentioned a tiny little thing I hadn't heard previously...a bit of HRT. What benefits do you find from "a very low dose"? Are you taking HRT for bones or heart or overall endocrine health? Just curious. Happy Passover! Actually I spotted a matzoh ball recipe in Isa's BRUNCH book...if you don't have one already.

Thank you for the research in regard to standing and squatting while spinning. That is what I do during the hour I spin - even when the instructor says to sit, I still stand or squat so unless I hear otherwise, I will keep doing it since it is my favorite exercise and the one I actually do. I will try to start weight lifting although I detest it.